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Home My WebLink AboutBld-20-001817 "r OPermit*hi s��'� Amount 3 S— Permit expires 180 days from '-' {issue date 7 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH OCT Yarmouth Building Department 1146Route28 C ag3D. South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 aCjCONSTRUCTION ADDRESS: C. Pc.)- ASSESSOR'S INFORMATION: Map: Parcel: OWNER: 4 NASIvi1 2 a 1,„, S�^`� 7G 7�-7 -5'(t Mike McOleffireeilMtuction TEL. # CONTRACTOR: PO Box 52 NAME West DemilsvMAR02670 TEL.# esidential ❑Com Cell (508) 280-6964 -58633 HIC-1693 3 Cost of Construction$ Home Improvement Contractor Lic.# Construction Supervisor Lie.# Workman's Compensation Insurance: (check one) ❑ I am the homeowner ❑ I am the sole proprietor I have Worker's Compensation Insurance Insurance Company Name: Worker's Comp.Policy# WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares ( )Remove existing*(max.2 layers) Insulation 17 Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: 54'T5 K('o Location of Facility I declare under penalties of perjury that the statements herein contained are true and correct to the best of my knowledge and belief. I understand that any false answer(s) will be just cause for denial or revocation f my license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: CC � Date: 1 d )3- )1 Owners Signature(or attachment) Date: /c /:3- l/f Approved By: Date: la —2 /p Building Offici de ' ee) EMAIL ADD : Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No DocuSign Envelope ID:639E8620-3082-4567-BBF4-5DB7F8BF5CCE "7 81 -7 Z-} q 'IF Z RISE S, - e_f'15''Ste` t2 -Z t ENGINEERING" OWNER AUTHORIZATION FORM I, HRISTO DOKU (Owner's Name) owner of the property located at: 20 Bay Road (Property Address) West Yarmouth, MA 02673 (Property Address) hereby authorize , (Subcontractor) an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building permit and to perform work on my property. This form is only valid with a signed contract. DocuSigned by: cwilie F'S'Skt ature 8/28/2019 1 8:20 PM EDT Date RISE Engineering, a Division of Thielsch Engineering, Inc. 5 Dupont Avenue I South Yarmouth, MA 02664 1508-568-1926 www.RlSEengineering.com • '\ - The Commonwealth of Massachusetts I"=^=P_ ;il=G- Department of Industrial Accidents _ie111= • 1 Congress Street,Suite 100 _J_f-e• Boston,MA 02114-2017 ',�„ www mass gov/dia • W'Crorlcers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. • TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information �� *� Please PrintLegibly Name{Business/Organization/Individual): Michael McCarthy `Gr. r..�Tvuy� ,•-,C. Address: _ PO Box 52 - - City/State/Zip: - ------- Weit Annel � Zb • Are you an employer?Check the appropriate box: Type of project(required): 1.Q I am a employer with ', employees(full and/or part time).* 7. New construction 2.0I am a Sole proprietor of partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.). • 3.0I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. CI Demolition 10❑Building addition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will - ensure that all contractors either have workers'compensation insurance or are sole MO Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.0 Ism a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. Roof repairs These sub-contractors have employees and have workers'comp.insurance.* ❑ p • 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.[6ther 152,§1(4),and we have no employees.[No workers'comp.insurance required.] • *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. *Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and fob site information: ,••" Insurance Company Name: /Jc 4 t'c, .I Li c f>;114.., k r t•cc C-c Policy#or Self-ins.Lic.#: V 1 11/C 3-13 574i. Expiration Date: 1'-)• Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c.152,§25A is a criminal violation punishable bps fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify and t e ins J� 'enalties of perjury that the information provided above is true and correct. Signature: Date: I I' I I f ' Phone#: CiA) -t. 1c , Official use only. Do not write in this area,to be completed by city or town officiaL City or Town: Permit/License# Issuing Authority(circle one): • 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: *74 Fo/n~_/?,epeadlo-/ 4- Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement.Contractor Registration Type: Individual MICHAEL MCCARTHY Registration: 169393 P.O.BOX Expiration: 06/15/2021 WEST DENNIS,MA 02670 is Update Address and Return Card. SCA 1 Cr 20M-05/17 Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Individual before the expiration date. if found return to: Registratiotk Expiration Office of Consumer Affairs and Business Regulation —69393 06/15/2021 1000 Washington Street -Suite 710 MICHAEL MCCARThY — ,.: Boston,MA 02118 ./� i MICHAEL F.MCCARTHY j 6 RANGLEY LN. / a f• -. i/ / SOUTH DENNIS,MA-02660 Undersecretary Not V81ld.W lout Signature an Div ision atessittnai t:it; I�Ctartl � chuletes board of Buildingensure aft and Standards C u eA Eonaler. the-National Rimer' CS-058633 Wf �3t0dlig�ifgM �9111..! y •:, '-.. PO soxsz '' -Z:t.';SO;g4./ • WEST 4 "offer °att 'w .•vam NiraaaNiear .1)14 r.f .itk- .. 'Mdo1 NA71@NAIL MOIR Comm o t iimoluawisna._. • OSHA 00155871 .., 0 _ lJ S bepirbnant of labor ., �' ", • 2 rmain. ,' S Occ nal`S/Nty Heath Administration b. Michael McCarthy -ila heap+aa OtjfS itpMtella tofrUrooa+Para irSgetyaindH + f. ' "' ` L. 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